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Our goal is to provide you with enough information about these therapies that you can actively participate in your care. During this session, we will discuss the medical evaluation of infertility, the treatment that you will receive, and the risks involved with these treatments. Then we will show you how to get started with a treatment cycle and the hurdles involved. We will also introduce you to important aspects of infertility therapies including psychological factors and laboratory procedures.
When you visit the clinic, you will also receive written materials that will assist you in planning your infertility treatment. To meet the staff who will be involved in your care, please visit the Staff page on our web site.
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Now we will discuss the common acronyms used in our clinic, and the initial evaluations that are necessary prior to treatment with injectable gonadatropin medications.
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COH stands for Controlled Ovarian Hyperstimulation. Anyone using these injectable mediations will have some hyperstimulation of the ovaries. Our goal is to control this to avoid Ovarian Hyperstimulation Syndrome. This will be discussed in greater detailed later.
WIUI Washed IntraUterine Insemination. This involves washing a semen sample to isolate the sperm then placing the sperm into the uterine cavity using a thin catheter.
IVF In Vitro Fertilization. This is the process of removing eggs from the ovary through the vagina using a very thin needle. The eggs are then combined with sperm in a dish in the laboratory, and a few days later, a number of the resulting fertilized embryos are placed into the uterine cavity through the cervix.
ICSI IntraCytoplasmic Sperm Injection. This is used in conjunction with IVF and involves injecting one sperm into each mature egg to assist with fertilization. This will be discussed in greater detail later.
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There are currently no semen tests available that will provide all of the information that we would like to have about sperm function. Standard semen testing tells us how many sperm are present, how many are motile or living, and whether there is any evidence of infection in the form of white blood cells.
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Ideally, we would like to know something about the ability of sperm to penetrate the outer shell of the egg. At Duke, we have developed a test that can help us identify couples with a higher risk of fertilization failure. This test, called a Semen Profile, is offered to all patients considering in vitro fertilization and helps us decide if ICSI is appropriate for you.
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One of the tests completed for a semen profile is the swim-up. This is the total number of motile sperm which can assess your risk for a fertilization problem. The risk can be estimated as either <5%, 15% or >85%. If a fertilization problem is anticipated in a cycle of in vitro fertilization, fertilization can be assisted by the ICSI procedure. For patients undergoing COH, a semen analysis is generally the first test performed.
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There are some important considerations when collecting semen.
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Prior to beginning treatment we may want to gather some information about the anatomy of the female reproductive tract to help determine which treatment is appropriate for you. IVF and COH will require evaluation of the uterine cavity while COH will also require evaluation of the fallopian tubes.
Hysteroscopy is a procedure that allows us to see the uterine cavity and the wall of the uterus. A hysterosalpingogram (HSG) evaluates the uterine cavity and the fallopian tubes. Laparoscopy, hysteroscopy and chromotubation is an outpatient surgical procedure that evaluates the uterus, fallopian tubes and the ovaries.
Prior to treatment you may need to have one or more of the above procedures performed to rule out problems that may prevent a successful pregnancy. Your physician will help you decide which diagnostic tests are appropriate.
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In the next series of slides these will be discussed.
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In a normal cycle, the hypothalamus sends out the hormone GnRH in pulses. This stimlates the pituitary gland in the brain to release the gonadatropins, Follicle Stimulating Hormone or FSH and leutinizing hormone or LH.
These gonadatropins encourage the ovary to recruit a follicle, a cyst that contains an egg. Once a follicle starts to grow, the hormone production stops. This way only one egg becomes mature. The other eggs that were available in this cycle die.
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With superovulation, you will inject the hormone FSH every day. This will encourage the recruitment of multiple eggs in a cycle. All of the eggs that would have died this month are supported by this hormone to become mature and be available. This is the basis of both COH and IVF treatments.
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We offer several options for building your family. COH and IVF use the injectable medications to increase the chances of conceiving using your own sperm and eggs. We also offer sperm and egg donation for couples who require this. At any time during your treatment we will be happy to discuss adoption or discontinuing treatment and choosing childfree living. You may choose different options at different times in your treatment.
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There are several options for therapy when using the injectable gonadatropin medications. COH, combined with either intercourse at home or intrauterine insemination and oocyte retrieval with in vitro fertilization.
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Deciding between the treatment programs is often determined by diagnosis, insurance coverage (or lack thereof) and your comfort with the risks. If your tubes are blocked – IVF may be your only option. There is a greater success rate with IVF. The success with IVF is generally twice that of COH. There is also a lower risk of multiple gestation with IVF since we can control the number of embryos that are transferred to the uterus. With COH we cannot control the number of embryos that implant. Unfortunately, IVF is about three times as expensive and may not be covered by insurance. For assistance with the financial aspects of infertility therapies, ask about the ARC program.
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For couples doing COH you have a choice of having an intrauterine insemination or timed intercourse at home. There may be a slight increase in pregnancy rates with IUI, if the sperm counts are low. Choosing IUI may reduce some of the spontaneity of conception and involves an additional visit to the clinic. To make this decision you also need to understand your insurance benefits. Some carriers will deny any coverage if an IUI is performed. There is also a very slight chance of infection from passing the catheter into the uterus.
Your physician will assist you in deciding which therapies are appropriate for you.
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A common question in our clinic is "what are my chances of getting pregnant?" The answer will depend on several factors but is directly related to the age of the female partner, any known fertility factors and the type of therapy planned.
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Fertility decreases as women age and many women will not be successful without donor eggs after age 40. The age-related decline in fertility is associated with both a decreased chance of getting pregnant and an increased chance of having a miscarriage. Your physician will discuss with you your individual chances of conceiving.
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There are 3 primary risks of ovarian superovulation: 1.ovarian hyperstimulation syndrome (OHSS) 2. high order multiple gestation (triplets or more) and 3. a theoretical risk of ovarian cancer. There is also a risk of bruising or infection at the injection or venipuncture site as there is with any needle stick.
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Hyperstimulation Syndrome is referred to by insurance companies as "poisoning by ovarian hormones".
Everyone using these medications will have some degree of hyperstimulation. The risk of severe hyperstimulation requiring hospitalization is about 1%. The elevated levels of estrogen produced by the mature follicles causes fluid to leak out of your blood vessels. This is an exaggerated version of the same phenomenon that occurs with premenstrual syndrome.
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If the estrogen levels are high enough, fluid accumulates in the abdomen causing bloating which can restrict the movement of your diaphragm and make it difficult to breathe.
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Because the fluid is leaking out of your blood vessels you are actually dehydrated (even though drinking lots of fluids). This dehydration can cause nausea and vomiting which can make the dehydration more severe.
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If the dehydration becomes severe, the blood thickens, and increases your risk of forming a blood clot.
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This severe form of hyperstimulation Syndrome is rare and usually occurs in people who do not have regular predictable periods. It is also more common when a pregnancy has occurred. If you have the severe form, it may be necessary for you to receive IV fluids, be admitted to the hospital, and possibly have fluid drained from your abdomen using a small needle. This is called paracentesis. Again, this is rare.
It is very important to notify the clinic if your urine becomes dark in color or you are unable to drink fluids. OHSS generally occurs at the end of the cycle after you ovulated.
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When we talk about multiple gestation we are referring to triplets or more. Twins are common (20% of pregnancies with COH or IVF). If twins are not an acceptable option for you then these therapies are not appropriate. The risk of triplets or more is greater with COH though still only 3-5% of the cycles result in pregnancy. You should think about what you will do should you be faced with the dilemma of triplets or more.
The options include trying to carry the pregnancy with the increased chance of prematurity, or, electing to have a procedure to reduce the number of fetuses in the uterus to twins. We will encourage you to meet with a high-risk obstetrician before making any decisions should this occur. The risk of high order multiples is lower with IVF since we can limit the number of embryos that are transferred to the uterus.
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In the early 90's there were several reports that found a correlation between infertility and ovarian cancer. This led to speculation that infertility therapies might increase a woman's risk of developing this cancer. More recent studies have not been able to verify this correlation. There are 2 factors that can influence your risk. If you deliver your 1st child at a young age, your risk is less. If you take birth control pills for any period during your life -- your risk is less. However, because ovarian cancer is rare, studies have been unable to determine if there is an additional relationship between infertility therapy and ovarian cancer. Since there is no effective early screening test for ovarian cancer, we recommend that you continue your regular annual GYN visits for your entire life.
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Once you have decided which treatment options to pursue, you can proceed to plan a cycle. Call the triage nurse to discuss timing, ordering medications, schedule your monitoring visit, and complete any prior authorizations or precertifications. This may also be accomplished at your nurse visit if you ready.
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Most phone calls to our clinic during your treatment will be to the triage nurse. However, if you wish to schedule a return appointment with your physician or talk with our insurance representatives, please select that option from the phone menu. For after hours emergencies, please call the Duke Hospital Operator and they will connect with you with the physician on-call.
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Be sure to find out what coverage you have prior to beginning medications. This will help you avoid unexpected charges. The brochure you receive each year from your insurance plan is a good place to start. Then call your benefits office or the customer service department for your insurance plan. Our clinic representatives are also available for assistance but cannot quote to you your specific benefits. You will also need to determine if you require precertification or prior authorizations for the treatments or the medications. We are happy to perform these tasks for you but you must notify us that they are required. Please try to plan ahead to avoid delays in your treatment.
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For patients having IVF, payment for the complete cycle is required prior to beginning any medications. This is usually collected on the day of your first baseline ultrasound.
For patients having COH, payment is required when services are rendered, on the day of each visit.
For patients with managed care insurance, we must collect your co-pay prior to each clinic visit.
If you have weekend monitoring visits, please understand that we cannot accept payment by credit card on weekends. Please be prepared with check or cash.
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Prior to any treatment cycle you will need to complete several tasks. At the clinic appointment with your attending physician you will have a review of your medical history and previous testing, decide if further testing is required and determine which therapy is appropriate for you. If you are planning IVF, you may have a pelvic exam at this visit for a “trial transfer”. This will ensure that we can place embryos in the uterus. You may need an additional visit if you still have questions about which therapy is right for you. Your attending physician will decide how much medication you will take to stimulate the ovaries, and if you will require an additional medication to suppress ovulation during your treatment.
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If possible, you may combine this visit with your nursing visit. The nurses will teach you and/or your partner how to administer the different injections, review your specific treatment plan, and for pts undergoing IVF – sign consent forms and arrange for the screening lab work required by the CDC to check for infectious diseases. This may also be scheduled on a different day if more convenient for you. For IVF, all consents must be signed, screening labwork results received, and payment completed, before you can begin medications.
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There are two medications that everyone will use during a treatment cycle ñ gonadatropins and HCG. Some pts will also need a medication to suppress ovulation, such as Lupron. All pts doing IVF will require a medication to suppress ovulation as well as some patients doing COH. If not using one of these medications, we recommend that you have intercourse every 2-3 days during treatment, just in case you ovulate early. Common reasons for using this medication with COH include: Polycystic Ovarian Syndrome, using donor sperm or a history or ovulating early.
HCG is a medication given at the end of the stimulation phase to cause the eggs to become mature and release. If you are doing IVF, the egg retrieval will occur just before the eggs would release.
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Your physician will prescribe a daily dose of gonadatropin medication for you. A typical dose is between 2 and 4 vials or ampules per day and a typical treatment cycle will last for 12 days of these injections.
You physician will also decide if a suppression medication is appropriate for you. We will review all of your physician's
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At this visit we will also discuss choosing which brand of medications to use and we will provide you with instructions for obtaining your medications. We recommend using one of the mail order pharmacies that specialize in infertility medications. They can supply all of your necessary supplies and provide nurse hot lines for questions about medication mixing and administration. All of the prescriptions will have 12 months of refills.
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During a treatment cycle you will require a clinic visit every few days to monitor your progress. We will perform a vaginal ultrasound and possibly a blood test for estrogen levels. We will give you instructions at each visit for how to proceed. If blood tests were performed, we may need to wait for the results before finalizing your treatment plan. Discussions at these visits will be brief and will focus on your current treatment and response.
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We perform the ultrasounds on a "first come, first served basis". There may be times when waiting is unavoidable so we recommend that you bring a book or other distractions.
Our monitoring clinic is closed during the Christmas holiday. If you are planning a treatment cycle during this time, please check with the nurses before beginning medications. Our IVF lab also closes periodically during the year so again, please check with the nurses before making definite plans to begin medications.
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During your infertility treatment, we recommend that you continue your normal activities as much as possible. You may continue most prescribed medications and many over-the-counter medications. Please check with your physician if you regularly take medications. One medication we strongly recommend is prenatal vitamins or folic acid supplements. Any woman attempting conception can lower her risk of having a baby with certain birth defects by taking prenatal vitamins prior to conception. You may also continue your normal food and fluid consumption during your treatment. Again, you may discuss specific concerns with your physician.
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A treatment cycle consists of a series of hurdles. You must successfully complete one step before moving on to the next. We will now discuss the hurdles involved in COH and IVF cycles.
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A baseline ultrasound is performed prior to beginning a suppression medication such as Lupron. This is generally performed in the week before your next expected period. If large cysts are seen, we may need to repeat the ultrasound prior to beginning stimulation. Some cysts may interfere with the recruitment of multiple eggs. We will also confirm a pregnancy test before beginning medications, just in case.
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The goal of the stimulation phase is to recruit multiple mature follicles but not too many. Sometimes we recruit too many and need to cancel the cycle because of the risk of Ovarian Hyperstimulation syndrome. There may also be times when we don’t recruit enough follicles. If IVF was planned, we may recommend that you not proceed with retrieval but downgrade to COH and try a different strategy for stimulation the next time.
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We can usually estimate the number of mature eggs we expect to retrieve. Unfortunately there are times when we cannot retrieve all of the eggs and rarely, there are times that we do not retrieve any eggs. During the egg retrieval you will receive an intravenous catheter in your arm. Through this we will administer medications to create a state called conscious sedation. You will be very drowsy during the retrieval but not completely asleep. Most patients report only minimal discomfort.
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The day after the egg retrieval we will call and let you know how many eggs fertilized. The average number is about 60% of the eggs retrieved. If ICSI was performed, we will also tell you how many eggs were mature enough to be injected. Unfortunately, if there was an undiagnosed male factor problem, there are times when no eggs fertilize.
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After fertilization, the embryos are cultured in our incubators. There are times when the embryos do not continue to divide or cleave, and these nonviable embryos will not be transferred. We will transfer the number of embryos that will maximize your chances of pregnancy and minimize the chances of high order multiple gestation. You will not require any medications for the transfer and can resume your normal activities that day.
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When we order a pregnancy test, we get an actual number. This number is a measurement of the level of HCG – the pregnancy hormone – that is in your blood. If the number is lower than we expect, it may be a sign that the pregnancy will not continue. Even if the pregnancy test is positive, we encourage you to wait before sharing the news since there are still more hurdles to cross.
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If the first pregnancy test is positive, we will check another one 2-4 days later. We expect to see this number just about double every two days. If it does not rise normally, it may indicate a chemical pregnancy (where hormone is produced but no baby exists), an ectopic pregnancy ( a pregnancy outside the uterus), or may represent normal variation. We will continue to check the level every few days until it rises or falls or proceed with the ultrasound.
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The day of the ultrasound is very exciting. This is when we hope to confirm that you will have a viable intrauterine pregnancy. This is also the time we can determine how many babies are present. There are times when you have normally rising levels of HCG but when we perform the ultrasound there is no baby in the uterus. Once we see a baby in the uterus with a heartbeat, the chances of an ongoing pregnancy are very good.
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If a cycle is not successful, you will usually start your period a few days before we planned to do the pregnancy test. This period may be heavier than normal because of the increased estrogen levels. If you are doing COH, you may not begin another course of treatment with this period but should wait for one month. Still try to conceive during this off cycle! If you are doing IVF, we will require that you have a blood pregnancy test at the end of the cycle, even if you have started bleeding. There is still a chance of an ectopic pregnancy, even with IVF. Please call the triage nurse if you start your period so we can review the cycle with your physician and make plans for your care.
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Our goal is to see no cysts at the baseline ultrasound, have multiple eggs grow during stimulation (but not too many!), Retrieve multiple eggs, have normal fertilization, have all embryos continue to divide, transfer several back to your uterus and two weeks later have a positive pregnancy test. This test will double two days later and three weeks after that, an ultrasound will show a viable pregnancy in your uterus. At this time you would graduate from our care back to your referring obstetrician or we can assist you in finding an obstetrician.
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Infertility, regardless of whether it is a female or male factor problem, can be stressful for couples. We hope to help you understand some of the common reactions that can occur, strategies for coping with these reactions, and how to know when to seek professional help.
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Many patients experience feelings of depression or sadness when they discover they are unable to reproduce in the normal "at home" manner in which they expected to be able to achieve a family. You may feel a sense of loss or grief each month when you start a period and discover that once again, you are not pregnant. Some patients experience a more on-going sense of loss or diappointment
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Anxiety and tension are also common reactions when undergoing infertility treatment. Women may be anxious about the injections or egg retrievals. Men may be tense about having to "perform on demand". Most patients feel anxious as they wait for their pregnancy test results. Recognizing that these are normal reactions may help.
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Some patients may feel like they are at fault for not being able to become pregnant, or not being able to carry a pregnancy. Women may also have feelings of guilt about something in their past such as an abortion at an early age, and may fear this is the reason for their infertility. Patients who feel that becoming a parent is a central life goal may be particularly hard hit by infertility.
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It is not uncommon to feel that you are going through this alone. Infertility is unfortunately becoming more common with 15% of couples having difficulty conceiving. You may feel like you are the only couple having problems but be assured this is not the case. Many patients with infertility avoid friends or family members who have children. While this is a natural reaction, it can contribute to feelings of isolation
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Many couples report that infertility takes a toll on their relationship. It is not uncommon for two members of a couple to approach the infertility problem differently. Some men may want to focus their energies on fixing the problem, while many women often need to talk frequently about what they are going through. Sometimes partners have different thoughts about how to proceed with treatment. When couples approach the situation with different feelings and ideas, this can be very stressful. On the plus side, sometimes going through infertility has positive benefits for relationships. Some couples feel this struggle leads to increased closeness and understanding.
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Infertility treatment may take away the spontaneity of a couples' sexual relationship. You may have to produce sperm specimens on demand, or have intercourse at specific times. This can be very stressful.
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Understanding your infertility treatment is a first step to helping this stressful situation. We recommend that you take an active role in your treatment decisions and ask questions when things are unclear. The more you understand, the more comfortable you will be.
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Expect to experience some distress at certain times in a cycle for example, when you are taking shots, or when you start your period. It is normal to feel stressed or down at these times.
(*Seek Support) Finding a support group whether locally or on-line or just with a friend undergoing the same situation can be helpful. Remember you are not alone.
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Finding a support group whether locally or on-line or just with a friend undergoing the same situation can be helpful. Remember you are not alone.
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You should continue with your normal activities as much as possible. Focusing all of your energy on your infertility is a set-up for disappointment. It is a good idea to plan relaxing or distracting activities at known stressful times. For example, consider taking a warm shower before your injection or planning a weekend getaway while waiting for your pregnancy test.
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You might consider learning formal relaxation methods such as progressive muscle relaxation, yoga or meditation to help you cope with anxious feelings.
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Sometimes couples consciously or unconsciously blame unrelated problems on their infertility. Identifying and dealing with these other issues can be beneficial.
Try to identify when you are having unrealistic or unhelpful thoughts and ideas.
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Taking a break from treatment can also be very helpful. Couples often feel the pressure of time and age, but taking a few weeks or months off will not decrease your chances of conception and may help you emotionally.
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Seeking help from a mental health care professional does not mean you have a serious mental illness. Most couples who seek help are very normal. They are just trying to deal with a very stressful situation. Symptoms that may indicate that you may benefit from outside help include feeling sad or blue for more than a few weeks, having trouble making decisions or difficulty doing your normal daily activities. If you are having significant marital or sexual difficulties, you might consider consulting someone so they don't become more serious problems. You may also want to consult a professional if you are having trouble deciding what treatment to pursue or whether to continue treatment. Having an outside person to bounce ideas off of can be helpful.
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There is a range of psychological support services available for couples seeking help. These include short or long-term individual or couple therapy, sex therapy, relaxation training or biofeedback training, and weight management for those whose weight may be affecting their fertility. These services are available through Duke or you may seek someone locally if you prefer. Our goal is that you complete your infertility treatment mentally and emotionally intact.
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Here is a list of some websites that may be helpful.
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The following is a description of what happens in the laboratory during your IVF cycle. There are hurdles your sperm, eggs and embryos must overcome during their time in our laboratory.The eggs and sperm must be successfully recovered and combined to accomplish fertilization. If fertilization occurs, the embryos must continue with a process called cell division. Unfortunately, not all eggs that are retrieved will fertilize. Even if they fertilize, some embryos are not normal and will stop dividing before or after they are placed in your uterus. Others will develop into a normal, healthy baby. We understand the time spent waiting for results while your sperm, eggs and embryos are in the laboratory can be a very anxious time.
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On the day of the egg retrieval, the eggs are removed from the ovary along with the fluid that surrounded them in the follicle. The fluid is collected in a test tube by an embryologist. The embryologist uses a microscope to recover the eggs from the fluid.
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With the aid of a microscope, the embryologist searches the fluid from each follicle for a cumulus oocyte complexe ñ an egg surrounded by a mass of cumulus cells. Of all the eggs retrieved, some will be immature and some will be mature. Only mature eggs that fertilize can result in children.
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On the day the eggs are retrieved you will also collect a semen sample. Motile sperm will be isolated from the semen prior to being put into culture with the eggs or used for ICSI.
For some patients, sperm recovered and frozen previously will be used to inseminate the eggs.
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Insemination of the eggs is accomplished by either standard insemination (culturing the sperm and eggs together in a dish) or ICSI (Intracytoplasmic sperm injection). ICSI involves injecting a single sperm into each mature egg using a micropipette that is slightly wider than a sperm. ICSI does not guarantee fertilization. It produces the same number of fertilized embryos that would result from standard insemination if there were no factors preventing the sperm from penetrating the egg.
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The day after the retrieval, we will examine the eggs to determine which have fertilized normally. Embryos may be unfertilized, fertilized abnormally, or fertilized normally. Embryos that are not normally fertilized will not develop into a baby and these abnormal embryos are discarded at this time.
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The cells of the embryos continue to divide inside a protective covering called the zona pellucida. The division of each cell results in 2 new smaller cells. So as time passes, the cells become smaller and more numerous, but the overall size of the embryo remains about the same.
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On the second or third day, embryos will be placed in your uterus. This is called the embryo transfer. At this time the embryo has undergone several cell divisions. The number of embryos that will be placed in your uterus is variable and is dependent on a number of factors. This will be discussed with each couple at the time of transfer.
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Any viable embryos that are not transferred to your uterus may be frozen at this time. In future cycles, frozen embryos may be thawed and transferred to your uterus to attempt a pregnancy. Superovulation is not necessary when frozen embryos are used.
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Inside your uterus the cells of each embryo continue to go through cell divisions. On day 5 or 6, certain cells become specialized and migrate within the embryo. Some form a mass of cells that will develop into your baby, while others begin to form the placenta. At this time the embryo looks like a fluid filled balloon. The embryo is now called a blastocyst. Before the blastocyst can implant in the uterus, it must escape from its outer shell. The lower picture on this slide shows a blastocyst freeing itself from the zona pellucida in a process called hatching.
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We understand that it is a great leap of faith for you to be among several patients that will give us your eggs and sperm on any given day and then return in a few days to receive your embryos. Please rest assured that your concerns are a top priority with us. A number of safeguards have been implemented.
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In addition, all of the items that will come into contact with your sperm, eggs or embryos are labeled with your color code, name and medical record number.
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When your embryos are not being examined by an embryologist, they are kept under carefully regulated conditions in a chamber called an incubator. The incubator is labeled with your name and assigned color. One shelf in the incubator is reserved for each patient. As a final precaution, only one patientís embryos are handled at a time.
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When embryos are frozen they are placed in tiny plastic tubes called cryo straws. As with all other items, the cryo straws labeled with your name, medical record number and color code. The straws are placed in labeled goblets that are attached to labeled aluminum canes. These embryos are stored in liquid nitrogen.
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We are also concerned about making sure your embryos remain safe during their stay in our laboratory. Each of the incubators, dewars and all necessary instruments are connected to a sophisticated alarm system. If the reading on any of these instruments deviates from a specific range, an alarm is sounded and the staff automatically paged. The alarm continues to sound until one of our staff responds and fixes the problem.
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We hope this presentation has been helpful and provided the information you need as you embark on this new aspect of your infertility treatment. Please do not hesitate to ask any questions at any time during your treatment.
